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Psychiatric News   |    
Volume 39 Number 1 page 12-12
Psychiatric Practice and Managed Care
Documentation Is Good Medicine
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Recent audits of medical records have brought to light the variability with which psychiatrists and other mental health clinicians document their services. Although there are no national guidelines addressing what information is required for documentation of psychiatric services, it is clear that adequate documentation of services is essential—an appointment book is not sufficient.
When determining what to document, psychiatrists should consider the many functions of documentation, including the following:
APA members can direct CPT coding and documentation questions to the APA CPT Coding Service, which can be reached by e-mail at HSF@psych.org or fax at (703) 907-1089.

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